6a. Fever in adults Flashcards
history
exam
ddx
buffer
buffer
buffer
what is sepsis?
life-threatening organ dysfunction caused by a dysregulated host response to an infection
what is septic shock, how should it be treated?
a more severe form sepsis, technically defined as ‘in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone
Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion. This leads to a rise in blood lactate as the organs begin anaerobic respiration. This can be measured as either:
Systolic blood pressure less than 90 despite fluid resuscitation
Hyperlactaemia (lactate > 4 mmol/L)
This should be treated aggressively with IV fluids to improve the blood pressure and the tissue perfusion. If IV fluid boluses don’t improve the blood pressure and lactate level then they should be escalated to high dependency or intensive care where they can use medication called inotropes (such as noradrenalin) that help stimulate the cardiovascular system and improve blood pressure and tissue perfusion.
what score can be used outside ICU to assess a patients risk of mortality from sepsis if there is a ?infection
qSOFA
Respiratory rate > 22/min
Altered mentation
Systolic blood pressure < 100 mm Hg
qSOFA Scores 2-3 are associated with a 3- to 14-fold increase in in-hospital mortality. Assess for evidence of organ dysfunction with blood testing including serum lactate and calculation of the full SOFA Score.
Patients meeting these qSOFA criteria should have infection considered even if it was previously not.
red flags for sepsis ?
2,3,4
Behaviour:
- responds only to voice or pain/unresponsive
- acute confusional state
Vital signs:
- systolic bp <90 or drop of >40 from normal
- heart rate >130
- RR >25
Additional signs:
- non blanching rash, mottled, ashen, cyanotic
- not passed urine in last 18hr/ UO < 0.5ml/kg/hr
- lactate > 2
- recent chemo
when should the sepsis 6 be started?
when there are any red flags/ there is a suspicion of sepsis
what are the sepsis 6?
- Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD)
- Take blood cultures
- Give broad-spectrum antibiotics
- Give intravenous fluid challenges
NICE recommend a bolus of 500ml crystalloid over less than 15 minutes - Measure serum lactate
- Measure accurate hourly urine output
what is the SOFA score
used in ICU for patients ?sepsis
A SOFA score of 2 or more reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection.
amber flags for sepsis
- relatives concerned about mental status
- acute deterioration in functional ability
- immunosuppressed
- trauma/surgery/procedure in last 6 weeks
- rr 21–24
- systolic bp 91-100
- heart taye 91-130 or new dysrhythmia
- not passed urine in last 12-18 hours
- temp <36
- clinical signs of wound, device or skin infection
risk factors for sepsis
extremes of age; people who are frail, immunocompromised or immunosuppressed; people who have had recent trauma or surgery; people with a breach in skin integrity; and women who are pregnant, are post-partum, or have had a recent termination of pregnancy or miscarriage.
what are the sepsis 7 and 8
- Transfer to critical care may be needed to assess the need for central venous access and initiation of inotropes (increase cardiac output by increasing cardiac contractility) or vasopressors (increase blood pressure by increasing peripheral vascular resistance), to maintain perfusion pressure.
- Finding a source:
FBC: WCC may be high or low, thrombocytopaenia may indicate DIC
CRP - infection or inflamamtion
Creatinine, urea and electrolytes - dehydration, aki
LFTs - increased bilirubin or alanine aminotransferase (ALT) levels may indicate cholestasis or other liver dysfunction.
Clotting screen — if abnormal may indicate coagulopathy/DIC.
Urine analysis and culture, chest X-ray, CT for intra-abdo infection or abscess, LP for meningitis/encephalitis
additional investigations depending on the person’s clinical presentation — this may allow identification of the source of infection, pathogen(s) and sensitivities, and subsequent tailoring and/or de-escalation of antibiotic therapy if appropriate. Source control to eliminate a focus of infection may be possible, such as abscess drainage, debridement of infected tissue, removal of infected devices or foreign bodies, or surgery.
what is neutropenic sepsis
It is sepsis in a patient with a low neutrophil count of less than 1 x 109/L.
Low neutrophil counts are usually the consequence of anti-cancer or immunosuppressant treatment.
drugs that can cause neutropenia
Anti-cancer chemotherapy
Clozapine (schizophrenia)
Hydroxychloroquine (rheumatoid arthritis)
Methotrexate (rheumatoid arthritis)
Sulfasalazine (rheumatoid arthritis)
Carbimazole (hyperthyroidism)
Quinine (malaria)
Infliximab (monoclonal antibody use for immunosuppression)
Rituximab (monoclonal antibody use for immunosuppression)
recognition and management of neutropenic sepsis ?
Have a low threshold for suspecting netropenic sepsis in patients taking immunosuppressants or medications that can cause neutropenia
Treat any temperature above 38C as neutropenic sepsis in these patients until proven otherwise.
Treatment is with immediate broad spectrum antibiotics such as piperacillin with tazobactam (tazocin).
The other aspects of management are essentially the same as for sepsis however extra precaution needs to be taken. Time is precious so don’t delay antibiotics while waiting for investigation results.
pyrexia of unknown origin
buffer
buffer
buffer
buffer
buffer
what are some skin and soft tissue infections?
- cellulitis
- necrotising fasciitis
- scabies is a skin infection
what is cellulitis
Cellulitis is a bacterial infection that affects the dermis and the deeper subcutaneous tissues.
features cellulitis
Erythema (red discolouration)
Warm or hot to touch
Tense
Thickened
Oedematous
Bullae (fluid-filled blisters)
A golden-yellow crust can be present and indicate a staphylococcus aureus infection
commonly occurs on the shins
usually unilateral - bilateral cellulitis is rare and suggests an alternative diagnosis
systemic upset
fever
malaise
nausea
most common causative agent cellulitis
Streptococcus pyogenes
or less commonly Staphylococcus aureus
what classification is used to guide management of patients with cellulitis
Eron classification
Eron classification of cellulitis
I There are no signs of systemic toxicity and the person has no uncontrolled co-morbidities
II The person is either systemically unwell or systemically well but with a co-morbidity (for example peripheral arterial disease, chronic venous insufficiency, or morbid obesity) which may complicate or delay resolution of infection
III The person has significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable co-morbidities that may interfere with a response to treatment, or a limb-threatening infection due to vascular compromize
IV The person has sepsis syndrome or a severe life-threatening infection such as necrotizing fasciitis
who should be admitted with cellulitis
Has Eron Class III or Class IV cellulitis.
Has severe or rapidly deteriorating cellulitis (for example extensive areas of skin).
Is very young (under 1 year of age) or frail.
Is immunocompromised.
Has significant lymphoedema.
Has facial cellulitis (unless very mild) or periorbital cellulitis.
how to manage eron class 2 cellulitis
Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person - check local guidelines.
how to manage eron class 1 cellulitis? 1st line? other options?
oral antibiotics
- oral flucloxacillin as first-line treatment for mild/moderate cellulitis
oral clarithromycin, erythromycin (in pregnancy) or doxycycline is recommended in patients allergic to penicillin
how to manage class 3 and 4 cellulitis
admit usually for IV abx
oral/IV co-amoxiclav, oral/IV clindamycin, IV cefuroxime or IV ceftriaxone
Pre-septal/perioribital vs orbital cellulitis
Preseptal cellulitis is sometimes also referred to as periorbital cellulitis. It is an infection of the soft tissues anterior to the orbital septum - this includes the eyelids, skin and subcutaneous tissue of the face, but not the contents of the orbit.
This is in contrast to orbital cellulitis, which is an infection of the soft tissues behind the orbital septum, and is a much more serious infection.
Orbital signs (pain on movement of the eye, restriction of eye movements, proptosis, visual disturbance, chemosis, RAPD) must be absent in preseptal cellulitis - their presence would indicate orbital cellulitis
epidemiology preseptal celulitis and orbital cellulitis
- Preseptal cellulitis occurs most commonly in children - 80% of patients are under 10 and the median age of presentation is 21 months
- It is more common in the winter due to the increased prevalence of respiratory tract infections.
orbital cellulitis - Mean age of hospitalisation 7-12 years
Management of preseptal and of orbital cellulitis
- Refer to secondary care, orbital is much more time critical
- CT with contrast to differentiate between
+ FBC, blood culture, swab of any discharge
Periorbital: often oral co-amoxiclav and observation
Orbital: IV abx
what often precedes periorbital/orbital cellulitis
sinus infection, facial infection, insect bite
most common causative organisms preseptal/orbital cellulitis
Staph. aureus, Staph. epidermidis, streptococci and anaerobic bacteria
types of necrotising fasciitis
It can be classified according to the causative organism:
type 1 is caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type
type 2 is caused by Streptococcus pyogenes
features of necrotising fasciitis
acute onset
pain, swelling, erythema at the affected site
often presents as rapidly worsening cellulitis with pain out of keeping with physical features
extremely tender over infected tissue with hyperaesthesia to light touch
skin necrosis and crepitus/gas gangrene are late signs
fever and tachycardia may be absent or occur late in the presentation
risk fasctors necrotising fasciitis
skin factors: recent trauma, burns or soft tissue infections
diabetes mellitus is the most common preexisting medical condition, particularly if the patient is treated with SGLT-2 inhibitors
intravenous drug use
immunosuppression
most common affected site necrotising fasciitis
the perineum (Fournier’s gangrene)
management necrotising fasciitis
urgent surgical referral debridement
intravenous antibiotics
prognosis necrotising fasciitis
average mortality of 20%
severe itch with skin marks and scratch marks present for 2 weeks and getting worse, itch worse at night time- impacting sleep,
scabies
typical history and examination scabies
PC: severe itch with skin marks and scratch marks present for 2 weeks and getting worse
HoPC: itch worse at night time- impacting sleep,
Red flags: no fever, no weight loss, some fatigue but thinks this is due to reduced sleep due to itch, no night sweats, no lumps
MHx: none
DHx: none
Allergies: nkda
FHx: none
SHx: 1st year at uni, new sexual partner also experiencing severe itch
ICE: sleep is severely affected and is affecting uni work, skin marks affecting confidence, concerned it is infectious as her partner is having the same problem - is embarrassed to talk to anyone about it
o/e: Widespread erythematous papules on fingers, front of torso, genitalia, extensor surfaces of arms, scratch marks, thread-like tracks measuring around 5–10 mm in between fingers,
pathophysiology scabies
Scabies is a transmissible skin disease caused by the ectoparasitic mite Sarcoptes scabiei var. Hominis.
Itch is due to a delayed type-IV hypersensitivity reaction to the mite and mite products (faeces and eggs) so symptoms appear 4-6 weeks after infection.
Typical history common cold
PC: runny nose, sneezing, watery eyes, postnasal drip, fatigue, low grade fever, dry cough
HoPC: no SOB, no wheeze
what is the common cold?
The common cold is an acute, self-limiting, viral inflammation of the mucosa of the upper respiratory tract. The common cold actually describes an array of similar conditions caused by a vast number of different viruses. It is most often caused by infection with rhinoviruses (50-80%) and coronaviruses
most common pathogen common cold
rhinoviruses
management common cold?
Symptomatic:
Steam inhalation
Gargle salt water
paracetamol/ibuprofen
safety net
What is bronchitis?
Acute bronchitis is a type of chest infection which is usually self-limiting in nature.
It is a result of inflammation of the trachea and major bronchi and is therefore associated with oedematous large airways and the production of sputum.
typical history and EXAM bronchitis?
PC: cough: may or may not be productive, sore throat, rhinorrhoea, wheeze
o/e: no other focal chest signs other than wheeze
Management bronchitis
analgesia
good fluid intake
consider antibiotic therapy if patients:
- are systemically very unwell
- have pre-existing co-morbidities
- have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)
NICE Clinical Knowledge Summaries/BNF currently recommend doxycycline first-line
doxycycline cannot be used in children or pregnant women
alternatives include amoxicillin
Presentation of flu?
Rapid onset of:
Fever
Coryzal symptoms
Lethargy and fatigue
Anorexia (loss of appetite)
Muscle and joint aches
Headache (retro-orbital)
Dry cough
Sore throat
what is flu?
illness caused by the influenza virus =
an RNA virus
management of flu?
- check if PH reccomend treatment
Public health monitor the number of cases of flu and provide guidance on when there is enough flu in the area to justify treating patients with suspected flu. - Healthy patients that are not at risk of complications do not need treatment with antiviral medications. The infection will resolve with self care measures such as adequate fluid intake and rest.
- There are two options for treatment in someone presenting with suspected influenza that is at risk of complications of influenza:
Oral oseltamivir 75mg twice daily for 5 days
Inhaled zanamivir 10mg twice daily for 5 days
Treatment needs to be started within 48 hours of the onset of symptoms to be effective.
post-exposure prophylaxis flu
Post-exposure prophylaxis can be given to higher risk patients such as those with chronic diseases or immunosuppression within 48 hours of close contact with influenza. This aims to minimise the risk of developing flu and complications.
Oral oseltamivir 75mg once daily for 10 days
Inhaled zanamivir 10mg once daily for 10 days
complications of flu?
Otitis media, sinusitis and bronchitis
Viral pneumonia
Secondary bacteria pneumonia
Worsening of chronic health conditions such as COPD and heart failure
Febrile convulsions (young children)
Encephalitis
children influenza vaccination program?
- it is given intranasally
- the first dose is given at 2-3 years, then annually after that
- it is a live vaccine
dont give if ill or allergic to eggs
if immunosuppressed give injectable (not live) vaccine
adults influenza vaccination program?
annual influenza vaccination for all people older than 65 years, and those older than 6 months if they have:
chronic respiratory disease (including asthmatics who use inhaled steroids)
chronic heart disease (heart failure, ischaemic heart disease, including hypertension if associated with cardiac complications)
chronic kidney disease
chronic liver disease: cirrhosis, biliary atresia, chronic hepatitis
chronic neurological disease: (e.g. Stroke/TIAs)
diabetes mellitus (including diet controlled)
immunosuppression due to disease or treatment (e.g. HIV)
asplenia or splenic dysfunction
pregnant women
adults with a body mass index >= 40 kg/m²
health and social care staff directly involved in patient care (e.g. NHS staff)
those living in long-stay residential care homes
carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill (at the GP’s discretion)
when is influenza season? when should vaccine be given?
starts in november
vaccinate ideally between sep and early nov
what is pneumonia
Infection of lung tissue → inflammation → sputum filling airways
what is community aquired pneumonia (CAP)?
develops outside hospital or within 48 hours of hospital admission
what is hospital aquired pneumonia (HAP)?
develops more than 48 hours after hospital admission
or within 30 days of a hospital admission
what is aspiration pneumonia
develops as a result of aspiration - inhaling foreign material such as food
typical history and examination pneumonia?
PC: SOB, cough productive of sputum, fever, haemoptysis, pleuritic chest pain, delirium, sepsis
o/e: tachypnoea, tachycardia, hypoxia, hypotension, fever, confusion
Bronchial breath sounds - harsh breath sounds equally loud on inspiration and expiration
Focal coarse crackles - air passing through sputum
Dullness to percussion - due to lung collapse and/or consolidation
what scoring system is used in priamry care for pneumonia ? how do you interpret?
CRB65 criteria:
Criterion Marker
C Confusion (abbreviated mental test score <= 8/10)
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years
Patients are stratified for risk of death as follows:
0: low risk (less than 1% mortality risk) NICE recommend that treatment at home should be considered (alongside clinical judgement)
1 or 2: intermediate risk (1-10% mortality risk) NICE recommend that ‘ hospital assessment should be considered (particularly for people with a score of 2)’
3 or 4: high risk (more than 10% mortality risk) NICE recommend urgent admission to hospital
interpretation of point of care CRP test for penumonia
NICE also mentioned a point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy:
CRP < 20 mg/L - do not routinely offer antibiotic therapy
CRP 20 - 100 mg/L - consider a delayed antibiotic prescription
CRP > 100 mg/L - offer antibiotic therapy
what scoring system is used for pneumonia in secondary care? interpretation?
Criterion Marker
C Confusion (abbreviated mental test score <= 8/10)
U urea > 7 mmol/L
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years
NICE recommend, in conjunction with clinical judgement:
consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk)
consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk)
consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)
Investigations ?pneumonia
chest x-ray
in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests
CRP monitoring is recommend for admitted patients to help determine response to treatment
Management of CAP
Low-severity CAP:
5 days abx
1. amoxicillin is first-line
2. if penicillin allergic then use a macrolide or tetracycline
Moderate and high-severity CAP
1. dual antibiotic therapy is recommended with amoxicillin and a macrolide, a 7-10 day course is recommended
+ Consider a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia
discharge criteria pneumonia
NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings:
temperature higher than 37.5°C
respiratory rate 24 breaths per minute or more
heart rate over 100 beats per minute
systolic blood pressure 90 mmHg or less
oxygen saturation under 90% on room air
abnormal mental status
inability to eat without assistance.
what should happen after 6 weeks following pneumonia
CXR
All cases of pneumonia should have a repeat chest X-ray at 6 weeks after clinical resolution to ensure that the consolidation has resolved and there is no underlying secondary abnormalities (e.g. a lung tumour).
most common causes pneumonia
Streptococcus pneumoniae (50%)
Haemophilus influenzae (20%)
Moraxella catarrhalis in immunocompromised patients or those with chronic pulmonary disease
Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis
Staphylococcus aureus in patients with cystic fibrosis
what organism may be causing pneumonia in immunocompromised or COPD patients
moxarella catarrhalis
what organisms may be causing pneumonia in CF/bronchiectasis
Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis
Staphylococcus aureus in patients with cystic fibrosis
what is the definiton of atypical pneumonia? What can they be treated with?
pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain.
They don’t respond to penicillins and can be treated with macrolides (e.g. clarithomycin), fluoroquinolones (e.g. levofloxacin) or tetracyclines (e.g. doxycycline).
pneumonia caused by infected water supplies or air conditioning units. cheap holiday
Legionella pneumophila (Legionnaires’ disease)
how may legionnaires disease present
hyponatraemia (low sodium) by causing an SIADH
a mild penumonia causing erythema multiforme characterised by varying sized “target lesions” formed by pink rings with pale centres. It can also cause neurological symptoms in young patient
mycoplasma pneumoniae
pneumonia in a school aged child - chronic wheeze
Chlamydophila pneumoniae
other ddx more likely
pneumonia in a patient exposed to animals and their body fluids
Coxiella burnetii AKA “Q fever”
pneumonia in someone in contact with birds
Chlamydia psittaci
what are the 5 causes of atypical pneumonia
“Legions of psittaci MCQs”
Legions- legionella pneumophila
Psittaci - chlamydia psittaci
M – mycoplasma pneumoniae
C – chlamydydophila pneumoniae
Qs – Q fever (coxiella burnetii)
who may get fungal pneumonia? what is it called?
Pneumocystis jiroveci (PCP) pneumonia occurs in patients that are immunocompromised.
It is particularly important in patients with poorly controlled or new HIV with a low CD4 count. It usually presents subtly with a dry cough without sputum, shortness of breath on exertion and night sweats.
desaturation on exertion
management pneumocystitis jiroveci
co-trimoxazole (trimethoprim/sulfamethoxazole) known by the brand name “Septrin”
of the people exposed to TB, how many will develop it in their lifetime
5% get latent TB which becomes active a long time after infection
5% get active TB within 2 years
Typical history TB
Tuberculosis usually presents with a history of chronic, gradually worsening symptoms. Most cases are of pulmonary TB (around 70%) but they often have systemic symptoms.
Typical signs and symptoms of TB include:
Lethargy
Fever or night sweats
Weight loss
Cough with or without haemoptysis
Lymphadenopathy
Erythema nodosum
Spinal pain in spinal TB (also known as Pott’s disease of the spine)
what is the mantoux test for TB?
mantoux test - tuberculin skin prick - 5mm or more = positive
Positive in previous vaccination, latent TB or actvive TB
what is the quatiferon test for TB?
Interferon-Gamma Release Assays (IGRAs)
This test involves taking a sample of blood and mixing it with antigens from the TB bacteria. In a person that has had previous contact with TB the white blood cells have become sensitised to those antigens and they will release interferon-gamma as part of an immune response. If interferon-gamma is released from the white blood cells then this is considered a positive result.
positive in latent TB and active TB
think about pre-test probability before ordering this test
what is the gold standard invetsigation for active TB
Sputum culture.
Once cultured you can stain it (in same way as a smear) - more likely to be positive as has time to grow
more sensitive than a sputum smear and nucleic acid amplification tests
can assess drug sensitivities
can take 1-3 weeks (if using liquid media, longer if solid media)
If they are not producing sputum then hypertonic saline can be used to induce sputum that can be collected. They might require bronchoscopy with lavage to collect sputum samples.
Other cultures:
Mycobacterium blood cultures. These require special blood culture bottle.
Lymph node aspiration or biopsy
what is a sputum smear TB? results?
It is where a sputum sample is stained wither using ziel-neelson or phenoralamine - immunofluoresence test
3 specimens are needed
rapid and inexpensive test
stained for the presence of acid-fast bacilli (Ziehl-Neelsen stain)
all mycobacteria will stain positive (i.e. nontuberculous mycobacteria)
the sensitivity is between 50-80%
this is decreased in individuals with HIV to around 20-30%
what is a NAAT/PCR for TB?
allows rapid diagnosis (within 24-48 hours)
more sensitive than smear but less sensitive than culture
It provides information about the bacteria faster than a traditional culture but is only used where having this information would affect treatment or they are at higher risk of developing complications (i.e. in HIV).
how does primary TB present on CXR
patchy consolidation, pleural effusions and hilar lymphadenopathy
apical consolidation (top of lungs)
Development of tuberculous pleural effusion may occur as a result of delayed hypersensitivity reaction to mycobacteria or mycobacterial antigens in the pleural space in sensitized individuals [10] or by rupture of a subpleural focus of pulmonary disease into the pleural space
how does reactivated TB appear on CXR
upper lobe cavitation (gas filled spaces in the lungs) typically in the upper zones
how does miliary TB show on CXR
“millet seeds” uniformly distributed throughout the lung fields
most common site for TB infection?
lungs as get plenty O2
how may lymph node TB present
cold abscess” is a firm painless abscess caused by TB, usually in the neck. They do not have the inflammation, redness and pain you would expect from an acutely infected abscess.
where may you get granulomas TB
Pulmonary
Extrapulmonary:
lymph nodes
Pleura
Central nervous system
Pericardium
Gastrointestinal system
Genitourinary system
Bones and joints
Cutaneous TB affecting the skin
what is miliary TB
the immune system is unable to control the disease this causes a disseminated, severe disease
what type of vaccine is BCG
intradermal injection of live attenuated (weakened) TB
what must you do before BCG vaccine?
Prior to the vaccine patients are tested with the Mantoux test and given the vaccine only if this test is negative. They are also assessed for the possibility of immunosuppression and HIV due to the risks related to a live vaccine.
who is eligible for BCG vaccine?
Neonates born in areas of the UK with high rates of TB
Neonates with relatives from countries with a high rate of TB
Neonates with a family history of TB
Unvaccinated older children and young adults (< 35) who have close contact with TB
Unvaccinated children or young adults that recently arrived from a country with a high rate of TB
Healthcare workers
management latent TB
Otherwise healthy patients do not necessarily need treatment for latent TB. Patients at risk of reactivation of latent TB can be treated with either:
Isoniazid (with pyridoxine) and rifampicin for 3 months
(good for ppl under 35 if hepatotoxcity is a concern)
Isoniazid (with pyridoxine) for 6 months
(for ppl where rifampicin is a concern eg HIV or post transplant)
Management of active TB?
combination of 4 drugs used at the same time:
R – Rifampicin for 6 months
I – Isoniazid for 6 months
P – Pyrazinamide for 2 months
E – Ethambutol for 2 months
they are started on RIPE, what else should be prescribed?
pyridoxine (vitamin B6) is usually co-prescribed prophylactically to help prevent peripheral neuropathy from isoniazid
MoA and side effects rifampicin
“red and orange pissin”
hepatitis, organe secretions
inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA
MoA and side effects isoniazid?
“Im-so-numb-i-said”
peripheral neuropathy
hepatitis, orange secretions
agranulocytosis
inhibits mycolic acid synthesis
MoA and side effects pyrazinamide
hyperuricarmia causing gout
arhtalgia, myalgia
hepatitis
converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I
MoA and d=side effects ethambutol?
other considertaion
“eye-thambutol”
optic neuritis: check visual acuity before and during treatment
dose needs adjusting in patients with renal impairment
inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan
Fever pain score
Fever during previous 24 hours
P – Purulence (pus on tonsils)
A – Attended within 3 days of the onset of symptoms
I – Inflamed tonsils (severely inflamed)
N – No cough or coryza
A score of 2 – 3 gives a 34 – 40% probability (consider abx) and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis (give abx)
Management tonsilitis
- Oral phenoxymethylpenicillin (penicillin V?) for 5 or 10 days
- Clarithomycin or erythromycin(if penicillin allergic)5 days
Chronic tonsilitis referral criteria
> 3 episodes per year for 3 years
5 episodes per year for two years
7 episodes in a single year
Refer to ENT for tonsillectomy
Pathogen bacterial tonsilitis
GABS Group A Beta-haemolytic streptococcus
Two most common bacterial causes of otitis externa?
- pseudomonas aerginosa
- staphlococcus aureus
management of otitis externa
mild
1. acetic acid drops 2%
moderate: unclear if this is norm 1st line instead of above..
1. Topical abtibiotic and steroid eg:
Otomize spray (Neomycin, dexamethasone and acetic acid)
- orla fluclox if spreading
Fungal:
1. Clotrimazole ear drops
Most common pathogen and others : otitis media
Streptococcus pneumoniae
Other common causes include:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
If giving abx for otitis media, what is first line? what are alterantives?
- amoxicillin for 5 days
alternatives: erythromycin or clarythromycin
Management fungal otitis externa
clotrimazole ear drops
What should be avoided if perforated ear drum
Aminoglycosides (e.g., gentamicin and neomycin) are potentially ototoxic, rarely causing hearing loss if they get past the tympanic membrane.
Complication of otitis externa?
malignant otitis externa
Admission to hospital under the ENT team
IV antibiotics
Imaging (e.g., CT or MRI head) to assess the extent of the infection
pathophysiology otitis media
whilst viral upper respiratory tract infections (URTIs) typically precede otitis media, most infections are secondary to bacteria, particularly Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube
Presentation otitis media
otalgia
+ some children may tug or rub their ear
fever occurs in around 50% of cases
hearing loss
recent viral URTI symptoms are common (e.g. coryza)
ear discharge may occur if the tympanic membrane perforates
Examination otitis media
bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope
Who should get antibiotics for otitis media
Features:
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Otitis media with perforation and/or discharge in the canal
Patient:
Immunocompromised or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
